Wiki ? regarding # of dx

[mhstrauss]

Probably just another thing that I am overthinking, but I'd like to get some opinions on this situation, as this happens fairly often. Patient comes in for evaluation with our surgeon; has already gone through conservative treatment with PCP, so at this new patient visit, surgeon is ready to schedule surgery. For the # of dx in the MDM, since this is a new patient, we obviously get the points for "new problem to examiner". My question is, Does the pre-op work-up (labs, CXR, EKG) qualify for "additional workup"? The problem that the surgeon is treating is herniated disk, which has already been evaluated with an MRI...so technically the diagnosis is already confirmed. Just not sure if he should get credit for ordering standard pre-ops.

Any thoughts??

Thanks in advance!!

 

[OCD_coder]

I would give the provider credit for addtional work up planned since there is an element of cognitive process to the provider to determine whether or not the patient is healthy or not to perform surgery. I wouldn't penalize the provider because there is an established diagnosis prior to the patient's encounter. Would it support a level 5 based on this information, depends on the rest of the clinic note to determine that.

Many MAC(s) do not define what "additional workup planned" is. I have included Novitas's definition for reference.

18.What constitutes additional workup in the Amount and Complexity of Data grid for Medical Decision Making?

The number of possible diagnosis and/or the number of management options that must be considered is based on the number of types of problems addressed during the encounter, the complexity of establishing a diagnosis, and the management decisions that are made by the physician. For each encounter an assessment clinical impression or diagnosis should be documented. It may be explicitly stated or implied in documented decisions regarding management plans and/or further evaluation. Additional workup is defined as anything that is being done beyond that encounter at that time. For example, if a physician sees a patient in his office and needs to send that patient on for further testing, that would be additional workup. The physician needs to obtain more information for his medical decision making.

Date Posted: 10/16/2009, Date Revised: 07/15/2013

 

[mhstrauss]

Thanks for the reply!!